Signet Ring Cell Carcinoma Presenting Research Articles

S2190 A Case of Colorectal Signet Ring Cell Carcinoma Presenting as Ulcerative Recto-Sigmoiditis and Stricture

Introduction: Signet ring cell carcinoma accounts for about one percent of all colorectal cancers. It is an aggressive subtype of adenocarcinomas with the tendency for intramural spread and peritoneal carcinomatosis. Here, we reported a middle-aged male with circumferential colonic stenosis and inconclusive histology, found to have stage 4 colorectal signet ring cell carcinoma (SRCC). Case Description/Methods: A 41-year-old male without significant past medical history was referred to a gastroenterology clinic with bright red blood per rectum. Colonoscopy showed ulcerative recto-sigmoiditis with rectal bleeding, and there was stricture in the rectum, in the recto-sigmoid colon, and from anus to descending colon (Figure A). Biopsy was obtained from the stricture. The pathology revealed granulation tissue and abundant fibrinopurulent exudate showing small clusters, and individual atypical cells stained positive for CDX-2 immunostain. Unfortunately, the patient subsequently lost follow-up. Three months later, the patient was hospitalized for small bowel obstruction. CT showed markedly enlarged heterogeneous and edematous rectum, an abnormal mass within the posterior pelvis/rectum, retroperitoneal and pelvic lymphadenopathy with thickening and nodularity of the peritoneum. Biopsy was obtained from an inguinal lymph node with histological examination showing metastatic adenocarcinoma composed of poorly cohesive signet-ring cells (Figure B). Immunostains revealed that the neoplastic cells were strongly and diffusely positive for CDX2 and CK20 while negative for CK7, confirming a colorectal primary. Accordingly, the diagnosis of colorectal signet ring cell carcinoma was made. Discussion: The colonoscopic findings of colorectal SRCC could be nonspecific as diffuse circumferential thickening, stricture, or ulcerations. Typical pathological features may not appear on the initial biopsy sample. Immunohistochemical testing could help increase diagnostic yield and early identification of cancer cells. Our case hallmarked the importance of close follow-up for abnormal diffuse stricture and ulcerations in the colorectal area. These lesions may need to be rebiopsied, co-screened with abdominal imaging, and undergo an immunohistochemical investigation to characterize pathology further.Figure 1.: A: Colonoscopy: An intrinsic inflammatory circumferential fibrosis friable severe stenosis measuring 20cm (in length) * 9 mm (inner diameter) was found in the rectum, in the recto-sigmoid colon, and from anus to descending colon. B: Hematoxylin & eosin stain of tissue from lymph node showed metastatic adenocarcinoma composed of poorly cohesive signet-ring cells.

When the metastatic tumor presents as a primary tumor: Gastric signet-ring cell carcinoma presenting as advanced cervical cancer with ovarian metastasis

Ovarian cancer is the second most common malignancy of the lower part of the female genital tract. Primary signet-ring cell carcinoma (SRCC) of the ovary is rare and is most commonly metastatic from a primary lesion. Discerning between primary and metastatic SRCC of the ovary or cervix may be difficult. SRCC of the cervix is also a rare type of cervical carcinoma, and just like in the ovary, it is usually metastatic from a primary gastric tumor. Presented here is a case of a 37-year-old nulligravid, who presented with an increase in abdominal girth with associated abdominal pain. The initial impression was ovarian new growth, probably malignant, and cervical mass, probably malignant. On laparotomy, intraoperative impression was cervical with ovarian malignant tumor, primary unknown versus double primary. Histopathology revealed metastatic adenocarcinoma, right ovary, cervical stroma, omentum, and umbilical mass with anterior abdominal mass. Peritoneal fluid was positive for malignant cells. Clinical correlation, further workup, and immunohistochemical stains for CK7, CK19, CK20, and CDX2 were recommended. All immunohistochemical results tested positive in tumor cells and were noted to be consistent with metastatic carcinoma of gastric versus pancreatic primary. Further workup was done, and the biopsy from the esophagogastroduodenoscopy revealed poorly differentiated adenocarcinoma with signet-ring features, antral mucosa.

Rectal signet ring cell carcinoma presenting as stercoral ulceration and fecal incontinence

article: Rectal signet ring cell carcinoma presenting as stercoral ulceration and fecal incontinence - Gazzetta Medica Italiana - Archivio per le Scienze Mediche 2021 July-August;180(7-8):391-4 - Minerva Medica - Journals

Therapeutic plasma exchange in gastric signet ring cell carcinoma presenting as microangiopathic hemolytic anemia: a rare case report

Therapeutic plasma exchange in gastric signet ring cell carcinoma presenting as microangiopathic hemolytic anemia: a rare case report

Sa1329 - Metastatic Signet-Ring Cell Carcinoma Presenting as Acute Pancreatitis

Sa1329 - Metastatic Signet-Ring Cell Carcinoma Presenting as Acute Pancreatitis

A Case of Metastatic Gastric Signet Ring Cell Carcinoma Presenting as Tuberculous Peritonitis in an HIV/HCV Coinfected Patient

Portal hypertension due to cirrhosis is the most common cause of ascites. However, in patients with multiple risk factors for ascites, determining the etiology can sometimes present a diagnostic challenge. We present a case of new onset ascites in a 59 year old African American man with concomitant HIV (CD4 54) and chronic active hepatitis C infection, and suspected tuberculosis corroborated by elevated Adenosine Deaminase (ADA). In this unusual case, despite suggestive symptoms and signs, we found the cause of his ascites was neither infection nor liver disease, but rather metastatic gastric malignancy. Ultrasound with Doppler did not show cirrhotic features or vascular thrombus in the liver, while diagnostic and therapeutic paracentesis revealed a low Serum Albumin- Ascites Albumin Gradient (SAAG) and high ascitic fluid WBC count with monocytic predominance. Repeat ascitic fluid testing confirmed low SAAG, and ADA was elevated at 26.3 IU/mL. Laparoscopy revealed innumerable peritoneal lesions resembling tuberculous seeding of the peritoneum. However, peritoneal histopathology returned as metastatic signet cell adenocarcinoma. Esophagogastroduodenoscopy (EGD) revealed a large, firm, ulcerated gastric body tumor, and pathology was consistent with diffuse signet ring cell carcinoma. In this case, cirrhosis and tuberculous infection were highly suspected, however there was no evidence of cirrhosis, and although acid-fast smear and Quantiferon testing were negative, tuberculous peritonitis was strongly considered due to history of HIV and high monocyte predominance of ascitic fluid with elevated ADA. Both findings are suggestive of tuberculous peritonitis, however, ADA can also be elevated in the setting of malignancy and the pre-test probability of tuberculosis should be considered when sending ADA levels. Confirmation of the diagnosis with peritoneal biopsy is paramount.

Chylothorax and Chylous Ascites - A Rare Manifestation of Signet Ring Cell Carcinoma

Introduction: Chylous ascites is the accumulation of milk-like peritoneal fluid rich in triglycerides in the abdominal cavity. Chylothorax is the accumulation of this lipid-rich fluid in the thoracic cavity, and has rarely been reported in the literature as a consequence of malignancy. We present a case of a patient with signet ring cell carcinoma presenting with chylothorax and chylous ascites. Case Presentation: A 68 year old man with severe COPD and atrial fibrillation presented with shortness of breath. A chest x-ray (Figure 1A) and CT Chest (Figure 1B) revealed a right pleural effusion. Multiple thoracenteses revealed cloudy, white fluid. Infectious and cytologic studies on the fluid, as well as a whole body PET-CT were negative for malignancy.Figure 1Three months later the patient was admitted for reaccumulating hydrothorax, as well as new-onset ascites. A diagnostic paracentesis revealed milky, white chylous fluid (Figure 1C). Ascitic fluid analysis revealed Triglycerides of 500, WBC 605 (76% lymph), Amylase 13, Total Protein 3.1, Albumin 1.6 and a SAAG of 2.1. Blood work was not consistent with cirrhosis. A triple phase CT revealed normal liver size and parenchyma, with no identifiable hepatic or intra-abdominal lesions. EGD revealed a small area of mucosal nodularity in the 2nd portion of the duodenum (Figure 2A). A colonoscopy revealed mucosal thickening in the rectosigmoid colon (Figure 2B). Biopsies of both lesions were positive for poorly differentiated adenocarcinoma with signet ring cells.Figure 2The patient initiated therapy with FOLFOX regimen, however ultimately opted for hospice and expired three months later. Discussion: Chylous ascites is rare, with an incidence of approximately 1 per 20,000 admissions over the last 20 years. In the setting of malignancy, chylous fluid extravasation is thought to result from obstruction of the lymphatic channels by either direct tumor cell invasion or mass effect. Chylous ascites and chylothorax are often with lymphoma. There are only a few reported cases of chylous ascites or chylothorax from signet ring cell carcinoma. All reported cases depict this finding as a late manifestation of metastatic disease. Conclusion: Chylous ascites and chylothorax are exceedingly rare manifesations of signet ring cell carcinoma. All reported cases have been diagnosed in the setting of late stage metastatic disease. These findings should prompt further evaluation for an underlying gastrointestinal malignancy with EGD and colonoscopy.

Gastric Signet Ring Cell Carcinoma presenting as Obstructive Uropathy: A Diagnostic Conundrum

A 70-year-old gentleman, retired clerk and resident of Bihar presented with nausea, vomiting, giddiness, hesitancy and poor urine stream for 3 months. Loose stool, abdominal distension and altered sensorium were present since 10 days. The vomiting was 2 to 3 episodes per day, non-projectile, yellowish, non-foul smelling containing ingested food particles. There was no history of frequency, urgency, dysuria or hematuria. Patient was initially managed conservatively in a local hospital in Bihar as a case of gastroenteritis. His symptoms worsened and he developed altered sensorium. He was referred to another hospital, where his serum creatinine was found to be elevated from 0.9 to 3.6 mg/dl and bilateral hydronephrosis was detected on ultrasonography (USG). A detailed history of treatment was not available. He was then referred to the nephrology services in postgraduate student (PGi). There was no history of diabetes, hypertension or tuberculosis. He was a known case of seizure disorder since childhood and was on regular sodium valproate treatment. The patient had skipped his medication for the previous 2 days. On examination, there was pallor, pedal edema and facial puffiness. Pulse rate was 96/min, BP was 100/70 mm Hg and respiratory rate of 18/min. Respiratory system exa mination revealed bilateral coarse crepitations. Central nervous system examination revealed a Glasgow coma scale of 15 no. neck stiffness or any focal neurological deficit. Examination of the abdomen revealed increased abdominal girth with free fluid. Cardiovascular system examination was within normal limits. Digital rectal examination revealed grade 1 prostatomegaly. Throughout the course of the hospital stay, polymorphonuclear leukocytosis was seen. Electrolytes were normal. Serum alkaline phosphatase was raised but the other liver function tests were normal. Ascitic fluid serum-ascites allumin gradient (SAAG) was 0.8 and adenosine deaminase (ADA) was 12. The cerebrospinal fluid (CSF) examination was within normal limits. Pleural fluid cytology was suspicious of malignancy. Serum PSA was 3.8 ng/mL. Abdominal fat pad was negative for amyloid. Serum protein electrophoresis did not reveal any M-band. Ultrasound revealed bilateral hydrouteronephrosis with median lobe enlargement of prostate, normal liver and spleen. Contrast enhanced computer tomography (CECT) revealed multiple enlarged hilar lymph nodes, left pleural effusion with massive collapse and multiple sclerotic bony lesions. Non-contrast computerized tomography (NCCT) kidneys, ureters and bladder (KUB) showed globular kidneys with hyperdense contents within the left pelvicalyceal system suggestive of pyonephrosis/infected hydronephrosis. Patient was treated with antibiotics and his diarrhea improved 1,4Professor, 2,6Professor and Head 3Senior resident, 5Associate Professor 1,3Department of Histopathology, Postgraduate Institute of Medical Education and research, Chandigarh, India 2Department of Internal Medicine, Postgraduate Institute of Medical Education and research, Chandigarh, India 4Department of Urology, Postgraduate Institute of Medical Education and research, Chandigarh, India 5Department of radiodiagnosis, Postgraduate Institute of Medical Education and research, Chandigarh, India 6Department of Nephrology, Postgraduate Institute of Medical Education and research, Chandigarh, India

A Case of Metastatic Signet Ring Cell Carcinoma Presenting as Tuberculous Peritonitis in an HIV/HCV Coinfected Patient

Purpose: New onset ascites is most commonly due to chronic liver disease, but infectious and malignant causes must also be considered. This is a case of new onset ascites due to metastatic gastric signet cell adenocarcinoma in a patient with chronic hepatitis C and HIV coinfection. Case: A 59-year-old male with HIV (CD4 54) and chronic hepatitis C presented with abdominal pain, nausea, weight loss, and increasing abdominal girth for 2 months. Physical exam revealed bulging flanks with fluid wave and dullness to percussion. Laboratory findings were significant for hypoalbuminemia, absence of transaminitis, or thrombocytopenia, and elevated INR. PPD and Quantiferon-TB tests were negative. Right upper quadrant ultrasound with vascular dopplers did not show cirrhotic features or vascular thrombus. Abdominal CT was negative for intraabdominal organ abnormality. Diagnostic and therapeutic paracentesis revealed a low serum albumin-ascites albumin gradient (SAAG) and high WBC count with monocytic predominance. Peritoneal fluid was tested for cytology, acid-fast bacilli smear, culture, and gram stain, which were all negative. Repeat diagnostic and therapeutic paracentesis again revealed a low SAAG, and adenosine deaminase (ADA) testing was elevated at 26.3 IU/mL. The patient underwent a diagnostic laparoscopy with peritoneal biopsy. On laparoscopy, innumerable peritoneal lesions were noted, grossly resembling tuberculous seeding of the peritoneum. The presumed diagnosis of tuberculosis peritonitis was made and anti-tuberculin therapy was initiated. The following day, pathology from the peritoneal biopsy specimen returned as metastatic signet cell adenocarcinoma. An esophagoduodenoscopy was performed revealing a large, firm ulcerated tumor in the greater curvature of the gastric body. Pathology was consistent with diffuse signet ring cell carcinoma. Conclusion: As demonstrated by a recent meta-analysis, the ADA test has a high sensitivity and high specificity for revealing tuberculous peritonitis in ascitic fluid. This case underscores the importance of the ADA pre-test probability and of confirming the diagnosis with peritoneal biopsy, as malignancy may also present with high ADA levels.Figure: Ulcerated gastric mass, greater curvature.

Gastric Signet Ring Cell Carcinoma Presenting as Diffuse, Infiltrating Myositis—A Case Report and Review of the Literature

Gastric Signet Ring Cell Carcinoma Presenting as Diffuse, Infiltrating Myositis—A Case Report and Review of the Literature

Metastatic Signet Ring Cell Carcinoma Presenting as a Thyroid Diffuse Involvement: Report of a Case Studied with Q-elastographic and Acoustic Radiation Force Impulse Imaging Features

Metastatic carcinomas to the thyroid are rare in daily clinical practice. However, when encountered they represent a diagnostic challenge, since it is difficult to distinguish them from primary thyroid lesions, especially when occurring in patients with occult malignant history. Nevertheless, it is critical to differentiate a metastatic tumor from primary thyroid lesions, as the clinical management and the prognosis are different for the two entities. More recently, elastosonography opened new possibilities to ultrasound in different fields, such as thyroid nodule differentiation. Herein, we report a case of metastatic signet ring cell carcinoma to the thyroid studied with quantitative elastography and acoustic radiation force impulse imaging.

Primary signet‐ring cell carcinoma of the axilla

Primary cutaneous histiocytoid or signet-ring cell carcinoma represents an extremely rare adnexal neoplasm that most frequently presents on the eyelid but more rarely may present in the axilla. As this tumor can resemble metastatic carcinoma with signet-ring cells, especially lobular carcinoma of the breast, it can often present a diagnostic challenge. We present a case of cutaneous signet-ring cell carcinoma presenting in the axilla and outline the challenges of diagnosing this rare malignancy.

Metastatic Appediceal Signet Ring Cell Carcinoma Presenting with Non-Specific GERD symptoms

Metastatic Appediceal Signet Ring Cell Carcinoma Presenting with Non-Specific GERD symptoms

Primary gastric signet ring cell carcinoma presenting as cardiac tamponade

Primary gastric signet ring cell carcinoma presenting as cardiac tamponade is difficult to diagnosis early. Patients are generally asymptomatic until the disease is advanced. General practitioners usually focus on the initial symptoms related to pericarditis and pericardial effusion. We report a case of signet-ring cell carcinoma of the stomach presenting as cardiac tamponade with pericarditis and pericardial effusion but without any gastrointestinal symptoms. A 49-year old woman was admitted because of progressive dyspnea and cough. Chest X-ray revealed an increased cardiothoracic ratio and a small amount of bilateral pleural effusion. Two dimensional ultrasonographic echocardiography pericardial effusions with atrial and right ventricular early diastolic collapse were found, establishing the diagnosis of cardiac tamponade. Pericardiocentesis was performed and 420 mL of bloody fluid was taken. The patient died of respiratory failure and cardiac arrest on October 28, 2009. Post-mortem examination revealed diffuse gastric mucosa erosion and edema with stomach mucosa incrassation in the greater curvature. The primary lesion was histopathologically diagnosed as signet-ring cell carcinoma of the stomach.

A case of stomach cancer metastatic to the uterine cervix

Signet-ring cell carcinoma presenting in the uterine cervix is rare. Although the incidence is rare, the gastrointestinal tract should be considered as a possible primary site of metastatic uterine cervical cancer. We experienced a patient who underwent radical subtotal gastrectomy with right hemicolectomy and adjuvant chemotherapy due to gastric cancer and subsequently suffered from recurrence at the uterine cervix. Laparoscopic radical hysterectomy with bilateral salpingo-oophorectomy with pelvic lymph node dissection was performed. We report a case of the stomach cancer metastatic to the uterine cervix.

Metastatic signet ring cell carcinoma presenting as a thyroid nodule: Report of a case with fine‐needle aspiration cytology

Metastatic carcinomas to the thyroid are quite rare in daily cytology practice. However, when present they may produce a diagnostic dilemma, particularly when they share some morphologic similarities with primary thyroid lesions and when occurring in patients with occult malignant history. Herein, we report a case of metastatic gastric signet ring cell carcinoma to the thyroid. Our patient presented with an isolated right thyroid nodule, which was clinically considered to be a primary thyroid neoplasm. Fine-needle aspiration (FNA) cytology of the nodule revealed a cellular specimen with cohesive fragments and scattered individual neoplastic cells. The neoplastic cells had enlarged nuclei, fine chromatin, and inconspicuous nucleoli. Nuclear crowding, molding, and grooving were prominent. Intranuclear inclusion-like clearance was identified. Some tumor cells also had eccentric nuclei, creating a signet ring cell appearance. The colloid was scant. These cytological features may be seen in cases of papillary thyroid carcinoma or signet ring cell follicular adenoma; however, the presence of the signet ring cells is unusual in primary thyroid lesions and raises the possibility of a metastatic lesion to the thyroid. In our case, the tumor cells were positive for AE1/AE3, mucicarmine, and periodic acid-Schiff, but negative for thyroglobulin and thyroid transcription factor-1. The patient was also found to have a 3.7-cm mass in the distal esophagus/proximal stomach. Biopsy of this mass showed an invasive signet ring cell carcinoma. The purpose of our study is to discuss the cytological features and the differential diagnosis of this unusual thyroid FNA case.

Occult gastric signet ring cell carcinoma presenting as spermatic cord and testicular metastases: “Krukenberg tumor” in a male patient

Krukenberg tumor is a well-known ovarian metastasis, usually of gastric signet ring cell carcinoma in female patients. Although gastric carcinoma is more frequent in men, to our knowledge, only few cases of counterpart testicular metastases have been described as yet. We report a 64-year-old patient who complained of right testicular pain. Right-sided orchiectomy was performed, and metastatic signet ring cell carcinoma of spermatic cord and testis was diagnosed through histological examination and immunohistochemistry. The following stomach biopsy confirmed the primary signet ring cell carcinoma in the stomach. This extremely rare form of metastatic dissemination resembles the Krukenberg tumor of ovaries. Immunohistochemical staining plays an important role in the differential diagnosis of spermatic cord enlargement.

Cervical Signet-Ring Cell Carcinoma Presenting as a Synchronous Primary Carcinoma with Uterine Adenocarcinoma

Synchronous primary gynecologic tumors are relatively uncommon with the diagnosis often made following initial surgery. A multiparous female in her 50s with postmenopausal bleeding was referred to our institution with a biopsy-proven diagnosis of endometrial cancer. Preoperative physical exam revealed a suspicious cervical lesion and upon biopsy she was found to have a signet-ring cell carcinoma of the cervix. Secondary to morbid obesity, the patient was not a candidate for a radical hysterectomy and was treated with curative radiation for stage IB 1 cervical carcinoma and clinical stage I endometrial carcinoma. Cervical signet-ring cell carcinoma is an extremely rare pathologic diagnosis. The preoperative discovery of synchronous primary gynecological tumors necessitates individualized planning and treatment.

Systemic chemotherapy of TS-1 and cisplatin for gastric signet-ring cell carcinoma presenting as cardiac tamponade

A 59-year-old man complaining of dyspnea, anterior chest oppression, and hypotension was diagnosed to have cardiac tamponade due to massive pericardial effusion. A cytological analysis of the pericardial effusion disclosed adenocarcinoma. An endoscopic study revealed gastric cancer in the lesser curvature wall of the middle body of the stomach, and signet-ring cell carcinoma was confirmed histologically. The gastric cancer was complicated by malignant pericardial effusion, and metastasis to the mediastinal lymph nodes. The patient was treated with pericardiocentesis followed by systemic chemotherapy consisting of TS-1 and cisplatin (CDDP). After 5 months, pericardial effusion disappeared and the primary gastric tumor decreased in size. Our experience suggests that the systemic chemotherapy of TS-1 and CDDP may be effective for controlling advanced gastric signet-cell carcinoma accompanied by malignant pericardial effusion.

Signet-ring Cell Carcinoma Presenting in the Uterine Cervix

Signet-ring cell carcinoma presenting in the uterine cervix is an uncommon neoplasm. It is usually a metastasis from a primary gastric tumor; only rarely, cervical involvement is the first manifestation of the disease. Primary signet-ring carcinoma of the cervix is extremely unusual, and it is always necessary to rule out a metastatic neoplasm. We report 3 cases of signet-ring cell carcinoma diagnosed in cervical biopsies. All cases were initially considered as metastatic, but a primary site other than the cervix could be confirmed in only 2 cases. Although autopsy was not authorized, a very comprehensive clinical workup and the evolution of the disease support the interpretation of the third case as a primary neoplasm. Primary signet-ring cell carcinoma of the cervix is an extraordinary event-the diagnosis of which requires excluding a metastasis from the gastrointestinal tract (usually the stomach), the ovary, or the breast.